Swallowing problems and dementia in acute hospital settings: practical guidance for the management of dysphagia

Abstract

-There is little evidence to support tube feeding in advanced dementia although it is still frequently used in acute hospital settings. Patients present with complex problems and are often unable to make decisions about their healthcare needs. Multidisciplinary teams may be challenged by the difficult ethical decisions they are required to make in the best interests of their patients. This paper guides decision making in the management of patients with dementia and dysphagia in the acute hospital setting. A structured approach to information gathering, assessment and management is outlined with practical application of recent published guidelines and research evidence, which ensures appropriate individualised care. KEY WORDS: acute care, dementia, dysphagia IntroductionGrowing numbers of patients with dementia and dysphagia are being admitted to acute medical wards with complex problems including reversible or transient medical conditions, acute stroke or other neurological aetiologies. Some patients may be approaching the end of their disease process and may present a diagnostic challenge.Current practice in the area of dysphagia and dementia is variable, with the use of artificial feeding, nasogastric (NG) tubes, percutaneous endoscopic gastrostomy (PEG) or radiologically inserted gastrostomy (RIG) frequently being used without adequate consideration of the suitability of such procedures. Clinicians should be aware that there is little evidence to support tube feeding in advanced dementia. The National Institute for Health and Clinical Excellence (NICE) guideline on dementia advises that tube feeding should only be considered where dysphagia is a transient phenomenon and that artificial feeding should not generally be used in people with severe dementia. 1Other recent publications help guide the decision-making process. 2,3 Dementia and dysphagia in acute hospital careSwallowing problems may be caused by dementia or by other factors. Physical illness or metabolic upset may lead to acute confusional state in cognitively intact older people and those with dementia. 4 Symptoms usually resolve once the acute illness has been treated. Acute confusion can impact on feeding and swallowing due to the decrease in functional skills and conscious level. It is well recognised that a decrease in swallowing efficiency and reserve in older people can result in dysphagia when acute physical illness is present. 5 Certain medications have a detrimental effect on swallowing. Antipsychotics may cause Parkinsonism and dystonia. 6 Antidepressants and benzodiazepines may cause drowsiness while other medications may lead to a dry mouth.It is important to recognise and treat depression in dementia as significant improvement in mood and function is possible. Depression may lead to a range of problems including lack of appetite, reduced motivation to eat or feed oneself, abnormal ideation about food, for example that it is poison, or anxiety about eating and swallowing. In severe depression the person may have stopped eating al...

Dysphagia: implications for older people

“…157,158,[160][161][162][163][164][165][166] The direction of discussions in this literature is that there remains much to do in clarifying the evidence base around decisions that need to be made -for instance extensive literature is available in relation to outcomes around PEG placement, 158,164 but how this is applied to specific populations or individuals (imminent vs nonimminent death; lacking capacity or not; different medical aetiologies; different co-morbidities present) awaits definitive answers. Decisions around nasogastric or PEG feeding and withdrawal of feeding support are particularly fraught areas.…”

Clinical decision‐making for complex feeding decisions: A national survey of current approaches and perspectives

“…Support for a focus on individual choices and quality of life was strongly indicated by the current study, which further identified the need for clinician self‐care and de‐briefing in this complex clinical area. In the dementia literature in particular, a growing body of work supports this view of feeding for comfort, which focuses primarily on the contribution of food and fluids to overall well‐being and quality of life, rather than nutritional needs . Similarly, as the population ages, there is a growing need for patient care in a palliative context.…”

A survey of acute neurology at a general hospital in the UK

“…Carroll and Zajicek described the experience in a 24-hour acute neurology unit in Plymouth. 3 They concluded that per 100,000 population, 10.8 hours of specialist registrar time and 11 hours of consultant time per week, 15 neurology beds and 90 outpatient appointments would be required. This study was performed before the European Working Time Directive came into force.…”

“…1,2 There has been recent helpful guidance around oral feeding difficulties and ethical dilemmas. 3,4 …”